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A friend once told me that people fear being “found out”—that humans are afraid that others will discover that they’re not really as smart or as pretty as they seem to be.

They got into good schools by luck and passed tests the same way, and, sooner or later, their employer and clients will find out. You ask yourself, “Is it enough, this job I’m doing? Am I OK?” From deep in the secret, dark hidey-holes of your mind, self-doubt whispers an answer: “No.”

Over time, you learn to conceal self-doubt. You cover insecurities, push them out of sight and muddle on, defenses at the ready. You get by. And sometimes—the best times—you confront these demons head-on and expose them for the liars that they are. You realize that “We are who we are as much because of our gaps and failures as because of our strength,”1 and, although clichéd, the premise of I’m OK, You’re OK still can ease you into self-acceptance. So you stand a little straighter, and, in the mirror of your mind’s eye, you catch sight of yourself as acceptable.

Skin at war

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Now look at the scarcely concealed face with acne. Acne is a condition that manifests through lesions and reddened swellings; raised infections with pitted aftermath; and blackheads, whiteheads and scars. This is the topography of a complexion at war and, more importantly, the visage of someone who has been found out. No successful dissembling, no cover. Just questions and endless self-examination: “Have I done something to deserve this?” “Is this punishment?” “Is it the wrong food, the wrong habits, the wrong hormones, the wrong genes—is it me?” This person lives with a calendar divided into good days and bad days, marked by embarrassment, awkwardness and shame.

Words that commonly are used when describing diseased acneic skin make matters worse. “Blemished” and “bad” most accurately refer to flaws in moral character and sinful tendencies, or at least these are the customary meanings in Judeo-Christian culture. In his book Grace and Grit (Shambhala Press, 2001), transpersonal psychologist Ken Wilber summarizes the different messages given about disease by the cultures and subcultures to which we’re exposed. He writes that disease is variously explained as the following.

“… a lesson you give yourself to learn from …” (New Age)

“… a punishment from God for sin …” (fundamentalism)

“… repressed emotions …” (pop psychology)

“… a product of physical, emotional, mental and spiritual factors … treatment must involve all these factors … but orthodox methods might be rejected …” (holistic)

“… retribution … if too many good things happen, something bad has to occur …” (magical)

“… an inescapable part of the manifest world … only in enlightenment is illness finally transcended …” (Buddhist)

“Men and women necessarily and intrinsically swim in the ocean of meaning, and sometimes drown in it,” Wilber points out.2 Wading through their own beliefs and feelings can be difficult enough for those with acne. But contending with the attitudes, the judgments and, at times, the heartless assumptions of others can prove overwhelming. It comes as no surprise that, according to a British Journal of Dermatology article, those with “definite acne” (12-plus lesions) had higher levels of emotional and behavioral difficulties, and that acne “appears to have a considerable impact on emotional health (14–16 years old).”3

Impaired quality of life

A 2005 Journal of the European Academy of Dermatology and Venereology study found that “irrespective of … severity … acne patients are at increased risk for anxiety and depression compared to the normal (sic) population; acne negatively affects quality of life; the greater the impairment of quality of life … the greater the level of anxiety and depression, and increased risk for anxiety disorder.”4

Teens with severe acne grow up differently. At a time of life when fitting into peer groups is especially important and when burgeoning hormones prompt thoughts of experimentation, a study focusing on gender, sexuality and romantic relationships posits this disturbing theory.

According to an article in Medical Hypotheses, “Acne’s conspicuous localization on the face and its ability to elicit reflexive disgust and avoidance in observers suggest a possible role in sexual selections and functions to ward off potential mates.”5 This means that those with severe acne often live marginalized lives. “Reflexive disgust” implies that they are unclean; and with the word “avoidance,” it is as though, like the lepers of old, they should ring a bell to warn of their approach.

Acne sufferers find themselves enmeshed in a web of misconceptions about the disease, in addition to undergoing difficult, time-consuming treatment options. In Patient Ed Counsel studies measuring patients’ and physicians’ comprehension of acne’s causes and its natural course, an average of only 13% were aware of its origins, and just 6% understood its progression.6 An Experimental Dermatology study revealed that 66% of patients believed that their acne would improve immediately after the first treatment, and 49% thought that the total treatment time took less than six months. Belief that acne is curable ranged from 49–96% in two different studies.7 When taking into account these statistics, it’s not surprising that a Canadian study found a need for “accessible, accurate … education on natural history of acne, pathogenesis … effectiveness and …duration of treatment.”7

Adults who continue to live with visible acne suffer psychosocially from its effects. In a 2005 study in the British Journal of Health Psychology, revealingly titled “Nobody likes damaged goods,” five main issues were determined from the sample of adults studied.8

• Powerlessness and the variable nature of acne

• Comparisons, self-image and identity

• Experience of general social interaction

• Relationships with family and friends

• Gender, sexuality and romantic relationships

Powerlessness and the variable nature of acne translate into feelings of helplessness, both in controlling the skin and depending on it. People expect order, or so science would have it. Instead, those who are afflicted with acne experience chaos.

Chaos and acne

Specific physical occurrences, such as hypercornification, increased oil retention, lipid abnormalities, inflammation, bacterial action, genetics, hormonal events and stress—which is defined as any change an organism undergoes, either positive or negative, contribute to acne. Yet, after so many years of research, according to Experimental Dermatology, “the exact sequence, precise interdependence and choreography of pathogenic events in acne, especially the ‘match that lights the fire,’ have remained surprisingly unclear.”7 The Chaos Theory, a scientific theory that searches for the underlying order in apparently random data, suggests that even if such a “match” is found, acne ultimately will remain unpredictable.

Pay attention

Meanwhile, the skin care profession offers clients treatments and care, either in tandem with a dermatologist or alone. Treatments can involve immediate and long-range plans, as well as education. Care, on the other hand, requires something else from practitioners. You understand deeply that you need to pay attention to the person who sits before you, whose life has been undone by an epidermis gone mad, and to the poor skin, whose lot it is to be so confused, ill treated and reviled by the one to whom it belongs. Attention to the person whose chances to “experience depth, relatedness and value in life”1 have been impaired. Attention to “diminished soulfulness,” the psychosocial consequence of having acne. When understood this way, “soul is not a thing, nor an object of religious belief; it is a quality or dimension of experiencing life and ourselves.”1

“Ancient psychology … held that the fate and character of each of us is born in mystery; Renaissance doctors said that the essence of each person originates as a star in the heavens.”1 How far we have fallen from those wondrous beliefs; how much greater the distance is for the acne sufferer.

Those who treat clients with acne are fervent believers that it is possible to soothe and quiet the disease. You seek not to control it because acne has so many variables. Rather, you search for more effective and faster solutions that cause less damage. You attempt to hold it off for longer stretches so that the client experiences fewer bouts.

In effect, you walk with your clients so that their journey is less lonely. You are heartfelt listeners—not psychologists—who offer attention to the stories told and the life being revealed. You bear witness to their grief because, in the stillness of your treatment room, it is safe to confess it. You encourage and exhort; you search for and find the client’s true face because acne, the thief, has robbed her of it. Lastly, you view “care as a continuous process … not to make life problem-free, but to give ordinary life the depth and value that come from soulfulness.”1